机器人辅助普胸手术的麻醉管理

Anesthesia management for robotic thoracic surgery

目的总结机器人辅助普胸手术的麻醉方法和术中管理。方法择期达芬奇手术（DaVinciS）系统辅助下行普胸手术患者12例，采用全身麻醉复合T4～8椎旁神经阻滞。所有患者均在麻醉诱导后插入双腔支气管导管，并由纤维支气管镜完成定位。在胸腔内操作期间实施单肺通气。术中监测呼吸功能及血流动力学指标，并行动脉血气分析。结果所有患者均顺利完成手术。诱导后动脉血二氧化碳分压（PaCO2）（35．2±3．6）133／／1Hg（1mmHg=0．133kPa），动脉血氧分压（Pa02）（213．3±57．5）mmHg；单肺通气30min后PaC02（37．9±4．8）mmHg，Pa02（125．3±36．5）mmHg；有58％（7／12）的患者出现脉搏血氧饱和度下降，但均大于0．90，经处理后均好转。麻醉时间（291．5±99．4）min，单肺通气时间（2063±93．4）min，均在可接受范围。术中失血量（171．7±110．3）ml。术毕气管导管拔除时间为停药后（16．3±4．5）min。次日晨均转回普通病房，按期出院。结论机器人辅助普胸手术为临床新开展的手术，呼吸循环功能可能会有不稳定，手术过程中需要单肺通气以保证手术侧肺的完全萎陷，如果发生低氧血症或CO2蓄积，应积极调整呼吸参数并提高吸人氧浓度，低氧严重时可在通气侧给予呼气末正压。全身麻醉复合椎旁神经阻滞能提供良好的麻醉及镇痛效果，对循环干扰较小。

Objective To explore the method of anesthesia and intra-operative management for robotic thoracic Surgery. Methods Twelve patients who underwent robotic thoracic surgery using the Da Vinci surgical system were anesthetized with general anesthesia combined with T.-s paravertebral block. After induction of anesthesia, a double-lumen endotracheal tube was positioned by bronehofibroscope to allow one- lung ventilation during intra-operative procedure. Hemodynamies and respiratory function were routinely monitored and arterial blood gas （ABG） were tested during operation. Results All patients could tolerate the anesthesia for robotic thoracic surgery and there was no hospital mortality. The arterial carbon dioxide tension （PaCO2） and arterial oxygen tension （PaO2） after induction were （35.2±3.6） mm Hg（ 1 mm Hg = 0.133 kPa） and （213.3 ± 57.5） mm Hg respectively; PaCO2 and PaO2 30 min after one -lung ventilation were （37.9± 4.8 ）mm Fig and （ 125.3 ± 36.5 ）mm Hg respectively. When the one-lung ventilation started about 58% （7/12） of the patient developed temporarily low SpO2 （over 0.90） and recovered to 0.95 soon when using 3 - 5 cm H20（ 1 cm H20 = 0.098 kPa） positive end expiratory pressure （PEEP）. The anesthesia time was （291.5 ± 99.4） rain, the time for one-lung ventilation was （206.3± 93.4） min, the volume of blood loses in operation was （171.7 ± 110.3 ） ml and the tracheal catheter extration time was （16.3 ± 4.5 ） rain, all the patients left ICU on the second day after surgery. Conclusions The anesthesia for robotic thoracic surgery with Da Vinci surgical system is multiplicity, the hemodynamics and respiratory function can be instable, it is a new challenge for the technology and management of anesthesia. Good one-lung ventilation is important for this surgery, ventilation parameter need to be adjusted when hypoxia occurred and PEEP could be used to the ventilated lung. General anesthesia combined with paravertebral block will be a good option for postoperative pain control and minimal hemodynamics disturb anee.